Transitional Care Coordinator

Altru Health System • Grand Forks, ND

6d

About The Position

Everything we do is underscored by a why — and that why is one another. Location: Altru Business Center 2401 Demers Ave Grand Forks, ND 58201 Summary: The Transitional Care Coordinator (TCC) reviews patients being discharged home with high risk for readmission and identifies needs for home-based services. Collaborates with patient care navigators, health coaches, social work, and other clinicians to facilitate appropriate referrals for post-acute care. The TCC also champions the home-based remote patient monitoring program by facilitating implementation, educating patients and providers, and monitoring readings and outcomes.

Requirements

• Registered Nurse | North Dakota Board of Nursing (NDBON) or Compact State Agreement | Prior to Start Date | HR Primary Sources
• Registered Nurse | Minnesota Board of Nursing | Within 12 Months of Start Date | HR Primary Sources
• Social Worker | North Dakota Board of Social Work Examiners | Prior to Start | HR Primary Sources
• Social Worker | Minnesota Board of Social Work | Prior to Start | HR Primary Sources
• Basic Life Support (BLS) | American Heart Association (AHA) | Within 90 Days of Start Date | Learning Management System
• Driver's License with Acceptable Driving Record | Driver's License - Current State Licensed | Prior to Start Date | HR Primary Sources
• This position requires proficiency in reading, writing, and speaking English to ensure effective communication in the workplace and with patients, families, and team members.

Responsibilities

• Reviews patients with high risk for re-admission and coordinates need for home-based services.
• Collaborates with navigators, social work, and payers to facilitate discharge planning needs.
• Collaborates with community resource persons, primary care providers and multidisciplinary team to deliver services that promote quality outcomes and continuity of care.
• Implements, evaluates, and maintains the remote patient monitoring program, including patient and clinician education and skills validation, policy and procedure review development, review and updating, proper care of equipment and serving as a resource to patients and end users.
• Completes all required documentation within required timeframes.
• Participates in quality assurance and performance improvement
• Performs home health visits as needed
• Other Duties as assigned or needed to meet the needs of the department/organization.

Benefits

• Altru offers a comprehensive benefits package to its full- and part-time employees.
• Excellent benefits include a health plan and 401(k) retirement plan.
• Other benefits include a dental plan, vision plan, life and disability insurance, education assistance, paid time off (PTO)

What This Job Offers

• Job Type: Full-time
• Education Level: No Education Listed
• Number of Employees: 1,001-5,000 employees